Nursing Safety and Care Practices Quiz

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Questions and Answers

What is the immediate priority when addressing the client's nausea?

Reposition the client on her side (correct)

Reposition the client on her back

Check the tube for functionality (correct)

Administer antiemetic medication

What method describes the correct transfer procedure for an elderly client with left-sided weakness?

Move the chair parallel to the right side of the bed, and stand the client on the right foot. (correct)

Place the chair at a right angle to the bed on the client's left side before moving.

Have the client place the left foot next to the chair and pivot to the left before sitting.

Assist the client to a standing position, then place the right hand on the armrest.

Which statement is accurate regarding the use of complementary healing practices?

Complementary healing practices interfere with the efficacy of the medical model of treatment.

Many complementary healing practices can be used in conjunction with conventional practices. (correct)

Conventional medical practices will ultimately replace the use of complementary healing practices.

Conventional medications are likely to interact with folk remedies and cause adverse effects.

After determining a client has a problem, which action should the nurse perform next?

Determine the etiology of the problem. Signup and view all the answers

What explanation is most appropriate for the behavior of the Hispanic parents offering only broth to their child post-surgery?

Hot remedies restore balance after surgery, which is considered a 'cold' condition. Signup and view all the answers

What is the best response by the nurse when a client becomes upset upon seeing his colostomy?

Instruct the client that the stoma will become smaller when the initial swelling diminishes. Signup and view all the answers

Which instruction should the nurse provide when a UAP places a client in a left lateral position for a soap suds enema?

Reposition in a Sim's position with the client's weight on the anterior ilium. Signup and view all the answers

How much diuretic metolazone (Zaroxolyn) should the nurse plan to administer if it is available in 5 mg tablets?

1½ tablets. Signup and view all the answers

What is the best position for an elderly male client receiving tube feedings via a gastrostomy tube?

Fowler's. Signup and view all the answers

What narrative documentation should the nurse enter when a client refuses blood tests?

Healthcare provider notified of client's refusal to have blood specimens collected for testing. Signup and view all the answers

What nursing action should the nurse implement when observing a client's wife supporting the client's arm correctly during passive range-of-motion exercises?

Acknowledge that she is supporting the arm correctly. Signup and view all the answers

What information should the nurse obtain first from a young mother complaining of increased anxiety?

Nutritional history. Signup and view all the answers

What immediate action should the nurse take if the TPN solution has run out?

Infuse 10 percent dextrose and water at 54 ml/hr. Signup and view all the answers

Which action should the nurse take when observing pain and irritation at the infusion site for a client receiving a cephalosporin antibiotic?

Initiate an alternate site for the IV infusion of the medication. Signup and view all the answers

What information should the genogram provide during a client's health assessment?

Genetic and familial health disorders. Signup and view all the answers

When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety?

Put bed rails up on the side of bed opposite from the nurse. Signup and view all the answers

What intervention has the highest priority in decreasing the client's risk of infection for those with burns?

Use of careful handwashing technique Signup and view all the answers

Which laboratory value is the most reliable indicator of chronic protein malnutrition?

Low serum albumin level Signup and view all the answers

Which action should the nurse take next if the operative permit is not signed and the client has questions about the surgery?

Inform the surgeon that the operative permit is not signed and the client has questions. Signup and view all the answers

Which factor in a client's history poses the greatest threat for complications during surgery?

Taking anticoagulants for the past year Signup and view all the answers

Which procedure is best for the nurse to follow when assisting a client from the bed to a chair?

With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair. Signup and view all the answers

Which steps should the nurse take when administering ear drops to an adult client? (Select all that apply)

Place the client in a side-lying position. Signup and view all the answers

Which instruction should the nurse provide to ensure optimal benefits from using a metered-dose inhaler?

"Compress the inhaler while slowly breathing in through your mouth." Signup and view all the answers

Which action should the nurse take first regarding a client who has refused to shower during her period?

Teach the importance of personal hygiene during menstruation. Signup and view all the answers

What is the best response by the nurse when the client notes that a newly prescribed medication reduces sexual drive?

"How will this affect your present sexual activity?" Signup and view all the answers

What should the nurse document when a comatose client winces and pulls away from a painful stimulus?

Document that the client responds to painful stimulus. Signup and view all the answers

How many milliliters should the nurse administer for diazepam, 4 mg IV push?

0.8 mL Signup and view all the answers

Which intervention(s) are correct when preparing to insert a nasogastric tube? (Select all that apply)

Place the client in a high Fowler position. Signup and view all the answers

Which observation indicates that the caregiver has learned how to use a gait belt correctly?

Standing on his wife's weak side, holding the gait belt from the back. Signup and view all the answers

Which nursing diagnosis has the highest priority for a client with an indwelling urinary catheter?

High risk for infection Signup and view all the answers

Which client instruction is important for altered sleep patterns related to nocturia?

Decrease intake of fluids after the evening meal. Signup and view all the answers

What is the best action for the nurse regarding an opened normal saline labeled 48 hours prior?

Discard the saline solution and obtain a new unopened bottle. Signup and view all the answers

Which intervention is best for providing care for an older incontinent client at risk for infection?

Maintain standard precautions. Signup and view all the answers

What should the nurse do when unable to distinguish the first sound while taking a client's blood pressure?

Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. Signup and view all the answers

What action should the nurse take first when a client's blood pressure reading is 156/94 mm Hg?

Compare the current reading with the client's previously documented blood pressure readings. Signup and view all the answers

What is the most likely outcome of a malpractice lawsuit against a nurse who rendered aid at a collision site?

There will be no judgment against the nurse, whose actions were protected under the Good Samaritan Act. Signup and view all the answers

Which intervention should be included in the instruction for preventing complications of immobility?

Perform range-of-motion exercises to prevent contractures. Signup and view all the answers

Which method is best for evaluating the client's ability to perform a dressing change at home?

Observe the client change the dressing unassisted. Signup and view all the answers

Which meal best meets the dietary needs of a client with cholecystitis?

Broiled fish, green beans, and an apple Signup and view all the answers

When bathing an uncircumcised boy older than 3 years, which action should the nurse take?

Retract the foreskin gently to cleanse the penis. Signup and view all the answers

What change in pharmacokinetic properties should the nurse anticipate when a client's prescription changes from PO to IV?

The onset of action of the drug will occur more rapidly. Signup and view all the answers

After abdominal surgery, which action should the nurse implement when an older client requests to go to the bathroom?

Assist the client to walk to the bathroom and do not leave the client alone. Signup and view all the answers

By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection?

Mode of transmission Signup and view all the answers

Which instruction is most important for the nurse to include for a client with limited mobility to prevent venous thrombosis?

Dorsiflex and plantarflex the feet 10 times each hour. Signup and view all the answers

In assisting an older adult client prepare to take a tub bath, which nursing action is most important?

Check the bath water temperature. Signup and view all the answers

Which stool characteristics should the nurse report to the health care provider as soon as possible?

Daily black, sticky stool Signup and view all the answers

How should the nurse respond when a client expresses a desire to die?

Talk with the client about her feelings related to her own death. Signup and view all the answers

Which document should the nurse use to develop nursing guidelines for a new mental health services department?

ANA's Scope and Standards of Nursing Practice Signup and view all the answers

Which client is most likely to be at risk for spiritual distress?

Roman Catholic woman considering an abortion Signup and view all the answers

Which intervention is most important in the care plan for a client at high risk for postoperative thrombus formation?

Encourage frequent ambulation in the hallway. Signup and view all the answers

Which nonverbal action should the nurse implement to demonstrate active listening?

Sit facing the client. Signup and view all the answers

What is the most appropriate response for a nurse when a seriously ill client expresses a desire to die?

Assess the client's feelings about their death. Signup and view all the answers

Which observation during a UAP's blood pressure procedure requires the nurse's intervention?

The UAP auscultates the popliteal pulse with the cuff on the lower leg. Signup and view all the answers

During a clinic visit, what environmental factor should the nurse assess for a child having difficulty going to sleep?

Description of the family's home environment. Signup and view all the answers

What should the nurse do first when a 2-year-old's peripheral IV rate is slowing?

Check for kinks in the tubing and raise the IV pole. Signup and view all the answers

What is the primary benefit of performing range-of-motion exercises?

Prevention of contractures. Signup and view all the answers

What dietary considerations are important for clients with cholecystitis?

Low-fat diet. Signup and view all the answers

The son has the right to waive informed consent for his mentally incompetent mother.

False Signup and view all the answers

Which action is most important for the nurse to implement when obtaining a lie-sit-stand blood pressure reading?

Stay with the client while the client is standing. Signup and view all the answers

What is the best intervention for a client who is angry about waiting to smoke?

Review the schedule of outdoor breaks with the client. Signup and view all the answers

Which serum laboratory value should the nurse monitor for a client with an NG tube to suction for a week?

Sodium Signup and view all the answers

What is the best response for a client asking about drinking juice daily to prevent urinary tract infections?

Cranberry juice stops pathogens' adherence to the bladder. Signup and view all the answers

What should the nurse document as the client's respiratory rate if a count of six respirations is followed by a cough and a second count shows eight respirations?

16 Signup and view all the answers

Which health promotion brochure is most important for a client with arteriosclerosis?

Decreasing Cholesterol Levels Through Diet Signup and view all the answers

What is the nurse's first action when finding a client crying behind a locked bathroom door?

Talk to the client and attempt to find out why the client is crying. Signup and view all the answers

What should the nurse implement first for a client who has not had a bowel movement in 2 days?

Assess the client's medical record to determine the client's normal bowel pattern. Signup and view all the answers

Which instruction is most important for a nurse to provide to a client with sacral redness?

Change positions in the chair at least every hour. Signup and view all the answers

What should the nurse do next after inserting a urinary catheter with no urine output in a postoperative client?

Leave the catheter in place and reattempt with another catheter. Signup and view all the answers

Which nursing action is best when discussing a client's depression with a healthcare provider in a public area?

Discuss the client another time. Signup and view all the answers

What should the nurse do first for a client unable to sleep despite following a routine?

Ask the client to describe the routine he is currently following. Signup and view all the answers

What should the nurse do after a client shows signs of confusion post-operative consent?

Assess the client's neurologic status. Signup and view all the answers

What is the first assessment the nurse should perform for a client struck by lightning and feeling faint?

Pulse characteristics Signup and view all the answers

What should the nurse do if parental consent for administering an antipsychotic medication to an adolescent client has not been obtained?

Do not give the medication and document the reason. Signup and view all the answers

What action is best when a client in a hospital reports difficulty sleeping?

Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. Signup and view all the answers

What is the nurse's priority action when a client feels faint while walking to the bathroom?

Gently lower the client to the floor. Signup and view all the answers

What should the nurse do in response to a client asking for a pain pill while laughing?

Ask him to rate his pain on a scale of 1 to 10. Signup and view all the answers

What is the best response for a client expressing concerns about her sexual relationship due to obesity?

Ask the client to talk about specific concerns. Signup and view all the answers

What intervention is most important when a postoperative client's respiratory rate increases from 18 to 24 breaths per minute?

Determine if pain is causing the client's tachypnea. Signup and view all the answers

What is the first action a nurse should take when assigned to care for a close friend in a hospital?

Explain the relationship to the charge nurse and ask for reassignment. Signup and view all the answers

What should the nurse encourage the client to do if questions arise about a newly prescribed medication?

Encourage the client to call the clinic nurse or health care provider if any questions arise. Signup and view all the answers

What action should the nurse take when observing an ambulatory client walking alone during a fire evacuation?

Remind the client to walk carefully down the stairs until reaching a lower floor. Signup and view all the answers

What action should the nurse implement after a needle stick occurs while removing the cap from a sterile needle?

Select another sterile needle. Signup and view all the answers

What should the nurse do after emptying 350 mL of pale yellow urine from a client's urinal, noting it's the first void in 4 hours?

Record the amount on the client's fluid output record. Signup and view all the answers

What action should the nurse include when administering liquid potassium chloride through a feeding tube?

Administer water between the doses of the two liquid medications. Signup and view all the answers

If an antihypertensive medication is missing from a client's postoperative prescriptions, what should the nurse do?

Contact the health care provider to renew the prescription for the medication. Signup and view all the answers

What should the nurse do first when administering medications through a nasogastric tube connected to low intermittent suction?

Turn off the intermittent suction device. Signup and view all the answers

For documentation of IV catheter placement in the client's right arm, which should the nurse record?

Right cephalic vein Signup and view all the answers

What client statement requires further assessment of the medication order during medication administration?

This is a new pill I have never taken before. Signup and view all the answers

What is the best action to take when providing wound care instructions to a client who does not speak English?

Speak directly to the client, with an interpreter translating. Signup and view all the answers

What assessment data provides the most accurate determination of the proper placement of a nasogastric tube?

Examining a chest x-ray obtained after the tubing was inserted. Signup and view all the answers

What should the nurse realize about the center of gravity for an elderly person during ambulation assistance?

Upper torso. Signup and view all the answers

What is the most important action for the nurse to implement when donning sterile gloves?

Keep gloved hands above the elbows. Signup and view all the answers

What should the nurse say first to a client tired of taking antihypertensive medications who wants to try spiritual meditation instead?

It is important that you continue your medication while learning to meditate. Signup and view all the answers

What is the primary source of information for a health assessment?

Client. Signup and view all the answers

Which comment from a client indicates effective teaching about diet and lifestyle modifications for high cholesterol?

I will limit my intake of beef to 4 ounces per week. Signup and view all the answers

How should the nurse record findings of a rash made up of multiple flat areas of redness on a client's arm?

Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. Signup and view all the answers

What question is most important for the nurse to ask a client who is 5'5'' tall and weighs 200 pounds during a preoperative assessment?

What is your daily calorie consumption? Signup and view all the answers

What action should the nurse take after suctioning a client's trachea for 15 seconds and large amounts of thick yellow secretions return?

Re-oxygenate the client before attempting to suction again. Signup and view all the answers

What should the nurse do for a client receiving nasogastric tube feedings who reports severe coughing?

After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. Signup and view all the answers

What should the nurse do first for a female client with a nasogastric tube attached to low suction who states she is nauseated?

Irrigate the nasogastric tube with sterile normal saline. Signup and view all the answers

Study Notes

Client Safety During Movement

When turning an immobile client, ensuring bed rails are up on the opposite side prevents falls.
Using a turn sheet is important but less critical than raising bed rails for safety.

Infection Control in Burn Patients

Handwashing is the most effective method to prevent infection, especially important for burn patients.
Topical antibacterial applications and visitor limitations are useful but secondary to proper hand hygiene.

Assessment of Malnutrition

Low serum albumin levels are a significant indicator of chronic protein malnutrition.
Serum transferrin has a shorter half-life and is less reliable for chronic assessments compared to albumin.

Preoperative Procedures

If the operative permit is unsigned, the nurse must inform the surgeon before witnessing the client's signature or answering questions.

Surgical Risks and Anticoagulants

Anticoagulant use poses a high risk for surgical bleeding complications.
Birth control pills and antibiotic therapy present lower risks in surgical contexts.

Assisting Clients from Bed to Chair

Positioning the chair at a correct angle and stabilizing the client's knees enhances safety during transfers.
Lifting clients under the axillae is dangerous; clients should use the chair's arms for support.

Administering Ear Drops

Place the client in a side-lying position and pull the auricle upward and outward for effective ear drop administration.
Cotton should be placed in the outer canal only, and the dropper should be 1 cm above the ear canal.

Proper Use of Metered-Dose Inhalers

Inhalers should be administered while inhaling slowly through the mouth, optimizing medication delivery to the lungs.

Addressing Personal Hygiene Concerns

Educating clients about proper hygiene during menstruation is essential when addressing their beliefs about bathing.

Neurological Assessments with Glasgow Coma Scale

Document purposeful responses to painful stimuli; assess responses to verbal commands next.

Medication Administration Calculations

Accurate calculations are key. For diazepam IV push: 4 mg equals approximately 0.8 mL.

Nasogastric Tube Insertion Protocol

Position the client upright and instruct them to swallow when the tube passes the pharynx, ensuring proper insertion technique.

Gait Belt Usage for Ambulation

Caregivers should stand on the weak side of the client when using a gait belt for safety and support.

Infection Risks with Urinary Catheters

High risk for infection is the priority concern when caring for clients with indwelling urinary catheters.

Managing Nocturia

Reducing fluid intake after the evening meal helps decrease nocturia, improving sleep.

Sterile Technique in Wound Care

Discard any opened saline solution older than 24 hours to maintain sterility during wound care.

Infection Prevention for Incontinent Clients

Maintaining standard precautions is crucial to prevent infection in older, incontinent clients.

Blood Pressure Measurement Techniques

Wait 30-60 seconds after deflating the cuff to ensure an accurate second blood pressure reading.

Legal Protections in Emergency Situations

The Good Samaritan Act protects the nurse from malpractice claims when providing reasonable care in emergencies.

Health providers must obtain informed consent to avoid negligence, even if family members believe the patient cannot handle the information.

Safety During Blood Pressure Readings

Staying with the client while standing is crucial for their safety during blood pressure measurements.

Client Anger Management

Review the schedule of breaks with an agitated client, providing clear communication and managing expectations.### Nursing Actions and Rationale
Reviewing the schedule for outdoor breaks is crucial for maintaining client trust and communication.
Close monitoring of sodium levels is important for clients with prolonged NG suctioning due to potential fluid loss.

Patient Education

Cranberry juice is effective in preventing urinary tract infections (UTIs) by reducing bacterial adherence to the bladder.

Respiratory Assessment

Document the respiratory rate based on the most accurate count, which should not include interruptions from coughing.

Health Promotion

Focus on decreasing cholesterol intake as it is a significant risk factor for arteriosclerosis, more so than other factors such as smoking cessation or stress management.

Client Emotional Support

Engage directly with clients in distress to assess their situation and provide immediate support.

Bowel Movement Assessment

Assess a client’s normal bowel patterns before implementing interventions for constipation.

Pressure Ulcer Prevention

Encourage frequent position changes for clients to prevent pressure ulcers, particularly in wheelchair users.

Urinary Catheterization Procedure

If urine is not produced during catheterization, leave the initial catheter in place and attempt a second catheterization to correctly locate the bladder.

Maintaining Client Confidentiality

It is essential to discuss client issues in private to maintain confidentiality, avoiding discussions in public areas.

Sleep Promotion Techniques

Assess a client's current sleep routine before introducing changes to their care plan for insomnia.

Postoperative Client Monitoring

Assess neurological status if a client expresses confusion after signing a consent form to ensure understanding and legality of consent.

Initial Assessment Following Injury

First assess the client's pulse rate and regularity after being struck by lightning due to the risk of electrical injury.

Medication Administration for Minors

Withhold medication from minors until proper parental consent is obtained, ensuring documented reasoning for the decision.

Enhancing Sleep Hygiene

Incorporate a client's typical bedtime routine into their care plan to improve sleep quality.

Fall Prevention in Clients

Prioritize gently lowering a client who feels faint to the floor to prevent injury rather than seeking immediate medical assessment.

Pain Assessment

Utilize a pain scale to evaluate a client's pain experience, guiding appropriate medication administration.

Addressing Client Concerns

Invite clients to share specific concerns to facilitate open communication and effective counseling regarding sensitive topics like sexuality.

Respiratory Rate Interventions

Investigate the cause of tachypnea in postoperative clients, prioritizing the assessment of pain, anxiety, or fluid accumulation.

Professional Boundaries

Communicate openly with charge nurses about assignments involving close friends to maintain professional boundaries.

Immobility Complications Prevention

Perform range-of-motion exercises with immobile clients to reduce the risk of contractures and other complications.

Client Competence Evaluation

Assess a client's ability to perform self-care tasks like dressing changes through direct observation for accuracy.

Nutrition and Dietary Needs

Recommend low-fat foods for clients with cholecystitis to manage their dietary restrictions.

Hygiene Practices for Children

Gently retract the foreskin in uncircumcised boys over three years for proper cleaning to prevent infection.

Pharmacokinetics of Medication Routes

Transitioning medications from PO to IV can lead to a faster onset of action, as IV administration eliminates the absorption phase.### Client Safety and Care
Assist clients to the bathroom to minimize fall risks, especially when they are on CNS depressive medications.
The use of a bedpan is unnecessary as long as client safety is ensured; assess the client's ability to communicate needs.
Regular dorsiflexion and plantarflexion are critical for clients with limited mobility to prevent venous thrombus formation.
Checking bath water temperature is essential to prevent burns when preparing an older client for a tub bath.

Stool Characteristics

Black, sticky stool (melena) indicates possible gastrointestinal bleeding and requires prompt reporting to a healthcare provider.

Client Management

Reassure apprehensive clients calmly when they express fears about procedures; this can help reduce anxiety.
Encourage clients facing terminal illnesses to pursue goals that bring them joy, such as planning a gathering with friends.
Observing blood pressure techniques is crucial; auscultation should be done at the proper site (popliteal pulse) when measuring in the lower extremities.

Grief and Mental Health

Assess the family environment for contributing factors when school-age children present sleep resistance; this is vital for promoting healthy sleep habits.
Grief counseling is essential for clients exhibiting normal grief behaviors after losing loved ones.

Medication Administration

Encourage clients to reach out with questions about medication, emphasizing the importance of consulting healthcare providers.
Follow proper protocols for medication administration through feeding tubes, including flushing with water between doses.

Emergency Situations

During evacuations (e.g., fire), ambulatory clients should be reminded to navigate safely, without requiring assistance like a wheelchair.
After a needle stick, dispose of the used needle safely and select a new one, rather than trying to disinfect the contaminated needle.

Postoperative Care

Medications prescribed preoperatively need to be renewed after surgery; contact healthcare providers if they are absent from postoperative orders.
Confirm nasogastric tube placement before administering medications, and turn off suction to facilitate proper medication absorption.

Documentation

Accurate documentation of IV placement is crucial for ongoing care; ensure the correct identification of vein and location used for insertion.

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Description

Test your knowledge on essential nursing safety protocols and infection control measures for patients. This quiz covers key topics like client mobility, infection prevention for burn victims, malnutrition assessment, and preoperative nursing responsibilities.